Family Practice International

CLINICAL INFORMATION FROM THE INTERNATIONAL FAMILY MEDICINE LITERATURE

Anne D. Walling, M.D.

Am Fam Physician. 2001 Feb 15;63(4):765.

Causes of Bad Breath in Elderly Patients

(Great Britain— The Practitioner, November 2000, p. 938.) The most common cause of bad breath in elderly patients is volatile sulfur compounds produced by gram-negative anaerobes in the oral flora. Certain foods can cause changes in breath that last up to 72 hours after ingestion. Oral malodor can also result from smoking, drugs and a range of acute and chronic diseases, including respiratory tract infection, diabetes mellitus, and renal or hepatic conditions. Some patients develop a fixed belief that they have oral malodor, although this is not apparent to others. This halitophobia is a fixed delusion that may be a variant of monosymptomatic hypochondriacal psychosis.

Principles of Pain Control in Cancer Patients

(Hong Kong— The Hong Kong Practitioner, August 2000, p. 382.) Optimal pain control in patients with cancer is based on preventing and managing symptoms. Key issues include the route of administration, scheduling of doses and choice of agent or combination of agents. If possible, the most pharmacologically effective agent(s) should be taken orally, on a regular schedule based on the half-life of the agent(s) with provision for upward titration of the regular dose and management of breakthrough pain. In general, nonopioid agents should be used first, followed in a stepwise fashion by weak opioids and nonopioids with or without adjuvants (codeine, tramadol, dextropro-poxyphene), and strong opioids with nonopioids with or without adjuvants (morphine, oxycodone, buprenorphine). Combinations of agents are commonly used to control symptoms and provide synergistic analgesic effect, making the anticipation and prevention of side effects particularly challenging in patients with cancer. Some causes of pain require nonanalgesic management. Radiotherapy may alleviate pain caused by pathologic fracture, bone metastasis or spinal cord compression; steroids are indicated for the management of raised intracranial pressure or hepatic capsule distension; and muscle spasm may respond to anticholinergic drugs and physical therapy.

Treatment of Diabetic Retinopathy

(Great Britain— The Practitioner, August 2000, p. 696.) In older patients with type 2 diabetes (formerly called non–insulin-dependent diabetes), retinal changes are often present at diagnosis. Fifteen years after diagnosis, 95 percent of patients with type 1 diabetes (formerly called insulin-dependent diabetes) have pathologic changes in the eye. The prevalence and severity of diabetic eye disease can be reduced by good glycemic control in both types of diabetes. If given at the appropriate stage in the disease, laser treatment can reduce blindness from retinopathy in up to 95 percent of patients. However, laser therapy is less effective for maculopathy and prevents blindness in only 60 to 70 percent of patients. Aspirin and ticlopidine have been shown to slow pathologic changes in early retinopathy, but clinical trials have produced disappointing results. Other medications that have been studied but have not improved diabetic retinopathy include aminoguanidines, aldose-reductase inhibitors and antioxidants. Growth hormone antagonists, antihypertensives, angiotensin-converting enzyme inhibitors and beta blockers are currently being studied in clinical trials. Pending new treatments, the mainstay of prevention and management of diabetic eye disease is screening and appropriate glycemic control.

Treatment of Genital Herpes

(Canada— Canadian Family Physician, August 2000, p. 1622.) In the United States, an estimated 21 percent of persons 12 years and older are infected with herpes simplex virus type 2 (HSV-2). The prevalence has increased by 30 percent in the past 15 years. Many patients with HSV-2 are asymptomatic, and an estimated 80 percent of cases are never diagnosed. Both overt and suspected cases should be confirmed by viral culture because of the long-term nature of the condition and its potentially serious physical and psychologic effects. Choice of treatment should be individualized, but the main treatment strategies are episodic or suppressive therapy. The primary infection should be vigorously treated with oral agents such as acyclovir, famciclovir and valacyclovir. Topical treatment alone is less effective than systemic therapy. Episodic therapy requires aggressive treatment of recurrences with these anti–HSV-2 agents. Suppressive therapy generally uses lower doses of acyclovir, valacyclovir or famciclovir on a daily basis. Whichever therapy is chosen, attention also should be given to educating the patient about taking precautions to prevent infection of partners or transmission to the fetus in the event of pregnancy, and providing support of the patient's emotional needs.